The Professions in Modernity and the Society of the Future: A Theoretical Approach to Understanding the Polyvalent Logics of Professional Work

Outline of the problem

A glance at the current state of research on the sociology of professions reveals a confusing picture. I find both predictions regarding the further development of professionalization and concerns about a trend towards deprofessionalization. ¹ Some authors equate professionalization with standardizing training in expert professions (e.g., Dent, Bourgeault, Denis, & Kuhlmann, 2016), some with a status group that persuades society to grant it a privileged position (e.g., McDonalds, 1999), while others prefer a stricter definition of the concept of profession, such as “orientation towards clients, possession of an intrinsic knowledge system, service ideals” (e.g. Stichweh, 1997, p. 97).

Likewise, there are quite diverse theoretical approaches to the phenomenon of the formation of professions, which at first glance even appear to contradict each other. Rather than playing the different theoretical approaches against one another, it seems more fruitful to regard them as complementary so as to make theoretical gains.

The most obvious starting point for theorizing about professions is occupational sociology. This can include both clarifying the subject matter of the expertise in question (distinguishing between the relevant fields of knowledge) and looking at the social dimension (i.e., who is authorized to employ and to act as representatives of the knowledge and how this expert status is achieved and consolidated).

On this level, as pointed out by Abbott (1988), we can gain some interesting insights which transcend the perspective of the theory of power. The starting point is the finding that the special status of the professions must be associated with a monopoly that is protected by statute. However, interwoven with this there is a more subtle systemic structure, (i.e., the calming of internal competition and tensions). If anyone were free to exercise his or profession, the work to which the profession’s members would feel committed would be subject to competition, which could only be mediated by the market. This could all too easily lead to a corruption of the work. In this vein, Freidson (2001), who had previously been known for his more critical stance towards professional dominance (e.g. Freidson, 1970), discovered the third logic of professions as an element that would be both productive and necessary for compensating the tensions between the markets and bureaucracy.

Here already our attention is drawn in the direction of a societal arrangement that allows or produces the autonomy of professions since professionals have the task of holding the tension between different perspectives, requiring the application of differing and irreconcilable logics of reflection and balancing them in their decision-making. This does not deny that the stabilization and maintenance of professional power are always associated with micropolitical positioning games. However, such games must themselves be seen as part and parcel of an overarching arrangement since professional autonomy needs to be fought for and defended, not only to satisfy the profession’s own interests but also to ensure that the professional decision maker’s role remains institutionally validated. Alternatively, referring to Evetts’ work (2013), the ideological and value-oriented elements of professional actions do not exclude or oppose but stabilize and legitimize each other, making the respective services of professional work possible.

Many professionals—especially medical doctors—are also always obliged to decide for other people who, even if they make such decisions, are not in fact in a position to assess what consequences they will have for the development of their autonomy. Thus, professionals have the task, which initially appears paradoxical, of establishing what their clients actually want while it is not yet evident since their ability to formulate or even be aware of their will may be restricted or unclear. This may be due to illness, lack of insight into the decision’s consequences or, in the case of children and adolescents, their not yet reaching the stage of maturity at which they can fully exercise their autonomy. In the last case, professionals may feel compelled to employ pressure or other communicative tricks to empower clients to do something without being able to understand why.

A doctor will accordingly attempt to induce some of his or her reluctant patients—by either using gentle hypnosis or painting a threatening picture—to agree to a treatment whose benefits they are unable to grasp and which initially appears associated only with pain and suffering.

Teachers act as professionals when they orient their curricula, the teacher-student interaction and the teaching materials stipulated by the examination requirements in such a way that their students can in the future more easily find their way around those cultures that require the knowledge imparted. The teachers may neither succumb to their students’ superficial wishes to “have it easy” nor teach and sanction them mechanically without considering the consequences for their students’ future development.

A lawyer who is qualified (as described above) and feels committed to the ideal of the professional-client relationship should not only establish whether some means of legal redress for his or her client exist but also whether the client will likely be embroiled in a detrimental spiral of hate. Over the long term, the latter’s consequences could damage the client more than would be offset by the settlement obtainable with the expected outcome.

For a critical sociologist, the cited viewpoints must appear totally euphemistic. For example, why should a person believe that a doctor is really concerned about his or her patient’s well-being and not simply about his or her own (covert) interests? Moreover, how can someone free oneself from the suspicion that the doctor is only interested in achieving self-gain?

However, from the sociological standpoint, it is more interesting that whether or not the professionals’ talk about establishing rapport with their clients can be taken seriously cannot be decided by an external observer (as one cannot see into another person’s mind). It is also true that the fact that one cannot know whether one can really trust a professional does not change one’s dependence on doctors, lawyers, teachers, psychotherapists, and other professionals. On both sides—that of the professionals and that of the clients—there is thus great uncertainty as to what is the case, what is the right thing to do and what motives drive what happens (i.e., whether it is in the clients’ interests or shaped by other interests). This dilemma can only be solved by reciprocal recognition of the subjectivity of the other since this is the only way that a stable and supportive relationship can develop, in which the critical decision processes can be balanced, and where there is trust in the honest and incorruptible attitude of the actor with the greater structural power (the doctor, lawyer, teacher, etc.).

Professionals and modern subjects would thus, in a sense, appear caught up in a circular way in an arrangement that both produces and presupposes the elements that constitute it. It is, therefore, crucial that there be confidence and trust in the system present in order to create both the professionals and the subjects who are enacted by it as individuals who act autonomously and also to stabilize their autonomy.

However, this also brings into relief the perspective of the theory of society, which any serious sociological theory of professionalization must address. On the one hand, this is a specific societal form of arrangement that permits professionality and subjectivity to enter the foreground as two complementary poles of a functionally differentiated society. On the other hand, the arrangement itself must be considered both the product and the starting point of the social practice and its evolution (cf. Stichweh, 1997).

What conceptual and theoretical instruments are then suitable for describing and reconstructing these complex relationships? While the classical approaches of the theory of professions provide some important pointers, it has not yet been possible to generate a comprehensive picture of the genesis and dynamics of professional actions.

In the following sections, we, therefore, turn to Günther’s (1976) logic of reflection, which takes its starting point at a level below the differentiation between subject and object (i.e., in the process of reflection as “doing ontology,” which differentiates between subject and object or another subject as an individual whose actions are autonomous). This attention to issues of logic and the associated ontological attitudes is not a “glass-bead game” (Hesse, 1949) but highly relevant for empirical reasons. For instance, this becomes clear in the case of a doctor who treats a difficult patient in one situation as a subject, an object or both or is able to oscillate between these alternatives. The way that this happens (or not) in turn also depends on a reflection (i.e., a practice).

Precisely for these reasons, it seems useful to employ the resources of polyvalent logic to explore the possibilities of a protosociology that offer insights into the above-mentioned complex dynamics (first section). I then take this as a basis for tracing the developments of the different societal arrangements that produce and reify the specific significance of the professional. I show this by taking the medical profession as an example. Since I also find polycontextural arrangements in the activities of other professions, it could be interesting to use this model to analyse their specific intrinsic dynamics; however, space constraints preclude their inclusion here (third section). Finally, I examine possible future risks to professions.

Expanding the focus by applying Günther’s logic of reflection

To capture the unavoidable problem in the theory of professions (i.e., others’ subjectivity is inaccessible to us yet needs to be considered), following Günther’s works (1976, 1978), I start from the assumption of multiple logical spaces (i.e., social reality is polycontextural ² ). Expressed in formal and abstract terms (see below for examples), different relationships between subject and object and the associated divergent rationalities, ontologies and epistemologies exist side-by-side. They complicate, interfere with and lead to each other reciprocally, with no possibility of attributing them to each other in a logical or causal sense. ³ These spaces are linked to and nested within each other via various reflexive relationships, with no possibility of shifting them to an overarching mode of existence (for a similar view, see Latour, 2013).

It might initially appear unusual to use instruments of logical reflection to address issues in the sociology of professions. However, professionals have always been confronted with irreconcilable institutional logics ⁴ in their everyday work and with relationships between subjects that seem equally complicated from a logical perspective. Thus, whether they consciously will it or not, they have always acted as empirical metaphysicists who decide for themselves ad hoc what the case is and how the boundary between subject and object must be drawn in each situation. For this very reason, it would seem expedient to conceive of professionals as experts in solving complex logical problems (i.e., problematic situations that cannot be dealt with in a trivial manner but need to be analysed with the instruments of a many-valued, polycontextural logic). For example, doctors must evaluate whether patients are so overwhelmed by their emotions that they are no longer able to decide what is good for them or conversely, whether they are capable of expressing these emotions and saying what they actually want. In the first case, the emotions appear to express the patients’ subjectivity, and doctors may want to follow the associated implications for action, while in other cases, they may want to ignore or bypass these. Thus, doctors have to decide which course to take on the basis of perceptions that can be ambiguous, requiring a complex reflection. I, therefore, examine in more detail the theory of polycontexturality to develop the appropriate metatheoretical sensitivity.

The concept of contexture, as coined by Günther (1976), refers to a reflexive configuration that expresses and arranges specific relationships between the self and itself and the self and the world, respectively. Günther calls for the introduction of the logic that can work with many-valued structures. The basic assumption is that in classical two-valued logic, the operation of negation constitutes a step that transcends the two-valuedness itself. As a result of the axiomatic structure of classical logic—the laws of identity, non-contradiction and the excluded middle—a reversible relationship between p (p is) and ~p (p is not) is established, where each position is determined by its difference from the other (e.g., a rose is red or not red). Günther points out that negation must necessarily transcend two-valuedness since, without it, there can be no reversible relationship although the associated reflexive relationship itself is not determined by the axioms. (In my example, an observer position is needed to open the space where it can be asked whether the issue is the rose is red or not red).

Accordingly, for Günther (1978), negation is the starting point for the development of a many-valued logic. It must thus be considered a transjunctional operation because it is required to constitute the unity of a certain duality or two-valued structure as a contexture. However, directing the attention to this constitutive operation simultaneously transcends it and makes it possible to develop further contextures. In this sense, the transjunctional operation is a reference to the respective observer positions. It makes it possible to switch between the contextures as different logical positions of reflection. (In my example, I could open a different logical space with the question and observer position as to whether or not the rose is thorny).

Additionally, several individual contextures can be joined to form a common metastructure. In this context, Günther discusses compound contextures (1979, pp. 191 ff). He views the linking of three elemental contextures as the minimum requirement for such a compound structure, with the third contexture regulating the relationship between the other two. To give an example from the social sphere, a judge might decide, based on the laws of the land, whether or not a criminal offence has been committed (i.e., whether the defendant is guilty or innocent). In contrast, a psychiatrist would ask whether the defendant was, in fact, capable of autonomously carrying out an act of will when the crime was perpetrated. The psychiatrist might then conclude that the defendant was suffering from a mental disorder that deprived him or her of the capacity for criminal responsibility. The question of the illness moderates the one about the capacity to take responsibility for an act of will, which in turn opens the possibility of the judge’s decision on the defendant’s culpability. We could consider other compound contextures and ask which contextures (or institutions) moderate the distinction as to when the competence to decide on the issue of culpability should be made on the basis of the law and when this should be left to a doctor and why the case is not decided on the basis of religion (e.g., to examine whether the perpetrator was possessed by the devil).

At this point, it is important to realize that applying the instruments of the logic of reflection should not be considered an epistemological “glass-bead game” (Hesse, 1949). Instead, it primarily serves to provide analytical concepts that allow access to the arrangements of reflexive relationships, which are operative in the practice of professionals.

Above all, this approach presents a more accurate picture of the emergence of the nested subject–object relationships of human interaction. To start, “I” stands for a simple reflexive relationship (i.e., reflection on “it” by “I”, whereby the subject, in reflecting, opposes itself to the world). Associated with the establishment of this relationship is the institution of a contexture (i.e., an epistemic centre with ontology since the subject that has been thus constituted is not only the world but also behaves towards the world).

However, as soon as we enter the social sphere (i.e., consider an alter ego), the world appears polycontextural. Whereas the “I-it” relationship implies that between a subject and an objectifiable object and accordingly creates a simple contexture, the situation with an “I-Thou” relationship is different. In this reciprocal relationship, another “I” behind “Thou” develops his or her own subject-object relationship – and thus also his or her own contexture with its ontology. Since the phenomenal perspective of “Thou” cannot be accessed from the monocontexture of “I”, the reflection of “Thou” adds something to the individual’s own reality that is not covered by the simple reflection of the material world (“it”) in the subject. We have no access to the subjectivity of the other.

It is also possible for us to reflect upon the relationship between two contextures. For instance, the “I” can consider the “it-Thou” relationship (i.e., another person’s perception and perspective). The reflective distance thus created allows the completion of an operation that discards the view, predicated on the binary structure, that a person’s own perception is the only possible one.

As pointed out, this becomes relevant in the relationship between the doctor as a professional and his or her patient. The doctor first considers the patient from the “I-it” perspective. With the illness as the focus, the patient is reified as a body. At the same time, an “I-Thou” relationship also develops between the doctor and the patient. However, in the interactional process, the doctor has to switch back and forth between the “I-it” and the “I-Thou” relationships to assign some of the patient’s statements to the illness and others to what he or she really wants. This becomes clear in the case of depression and resignation. The patient may state that he or she does not wish to go on living and, therefore, refuse further treatment. On the other hand, the doctor can view the patient’s hopelessness as a symptom of the illness and suspect that behind it, the wish to live will be recovered when the illness has been overcome.

From the analytical perspective proposed here, neither the will to live that the doctor postulates nor the patient’s hope or lack of it is real in the sense of possessing an ontological essence. Rather, both are systemic properties of an overarching arrangement that rests on attributions with no ontic foundation (in the sense of relating to something real) but gain significance at the latest when the polycontextural arrangement starts to be stabilized (i.e., when sufficient trust in the system develops to allow two subjects to emerge, who then both produce and stabilize the different reflexive perspectives that are required).

Professions as arrangements of self-conditioning observational positions of reflection

In this section, I attempt to use the tools of reflective logic (as developed above) to trace how arrangements evolve in professional contexts and how they are initially stabilized by society and then again subjected to a renewed process of transformation.

Once again, I present the medical profession and the doctor-patient relationship as an example and start by considering pre-modern medical treatment. ⁵ Given how medicine used to be practised, it seems to have been mainly based on interaction. As a rule, the doctor and the patient knew each other quite well. This led to mutually stabilizing arrangements where the doctor reified his or her patients, reducing them to mere bodies while perceiving them as autonomous subjects and likewise being perceived by them as a subject who respected their subjectivity and autonomy. Out of this, an interaction developed that gave rise to corresponding expectations, which in turn produced an arrangement by which trust in the interaction was created by that very trust in the interaction itself, which then motivated the patient to submit to the treatment procedures. This, in turn, was possible because it meant that in the interaction, the doctor could command credibility both in his or her formal role as a medical practitioner and as a person who is human (i.e., be in both the pathic and the empathic positions). If the resulting relationship became sufficiently stabilized, the patient could be expected to undergo the treatments that were typical of premodern medicine—which from our contemporary viewpoint, often did the patient’s health more harm than good.

The characteristics of the arrangement that evolved with modern medicine are quite different. The establishment of the hospital was the birth of an institution (Foucault, 2003) where as a rule, doctors and patients encounter each other as anonymous individuals. The patient is now primarily reified, treated simply as a body, with the other side being the doctor’s claim of objectivity. This, in turn, requires a frame in which the doctor appears disinterested and oriented exclusively towards the objectively observable facts of the patient’s disease. This again requires academic and scientific knowledge to have become sufficiently stabilized as an independent perspective of reflection (medical knowledge now accordingly appearing as “objective knowledge,” while alternative interpretations of illness (e.g., those of religion and magic) can be excluded as “subjective” beliefs.

Medicine should also be integrated into sufficiently stable institutions, which render it plausible that economic needs and political interests are set aside in medical treatment (i.e., the scientific viewpoint is not too strongly eclipsed by other rationalities). In France and Germany, this institutional stabilization was established by introducing a system of social insurance that provides the doctors with the means to act as medical practitioners, while the economic and political negotiation processes of this funding are left out of the picture.

The scientific objectivity and rationality of medicine thus appear as both an expression and an element of an overarching arrangement. This arrangement then produces trust in the system in which medical rationality appears rational and the patient is willing to endure the multifarious stresses and strains of medical treatment, including the violations of modesty, the infliction of pain during treatment and being forced to submit to the hospital as a total institution.

The future of professions?

The issue of sustaining trust despite the difficulty of not knowing what really is the case will continue to be one of the central problems of the medical profession, which will, in turn, maintain its special role. Medical treatment can only be provided permanently as a social system if patients can rely on the fact that the treatment is concerned about their health, not money, politics, scientific experiments or anything else (i.e., medicine is the “primary frame”).

This situation will also not change in the society of the future but will be further complicated by several factors since now, not only the subjectivity of the other appears inaccessible, but the spheres of knowledge that are assumed to be evident will seem increasingly permeated by uncertainty and the state of not knowing. We now know that reading and interpreting the body is anything but a trivial undertaking and itself beset by uncertainty. We also understand that bodily changes are options that can be associated with problematic side effects. Moreover, we are becoming increasingly aware that economic, legal and organizational complexities are also involved in the medical treatment process. In other words, the corresponding system and instrumental rationalities enter into the arrangements of medical treatment in such a way that the primary and the secondary frames are often no longer easy to distinguish.

The politically backed infiltration of austerity thinking into medical treatment, organized by the welfare states, is particularly responsible for softening the boundaries between the individual spheres and thus for eroding confidence and trust in the existing arrangements. This is illustrated well by the following example.

Since 2003, hospital services in the Federal Republic of Germany have used a system of lump sums paid for cases (diagnosis related groups, DRGs). It is based on the assumption that health policy has put a price on a statistical construct that was originally developed by epidemiologists for quality assurance purposes. Based on the virtual products that have thus been created, health economists have then been able to calculate the value of medical services as goods (Samuel, Dirsmith, & McElroy, 2005, p. 269).

Because of the new payment system in Germany, hospitals now have a strong incentive to uncouple medical indications from the benefits paid for by health insurance companies. As a result, whether or not intentionally willed, doubts slip into the doctor-patient relationship if a medical intervention was not decided for financial rather than therapeutic reasons.

Whereas until recently, the belief in the political and economic independence of medicine has had a calming effect on the precarious relationship between knowing and not knowing, this relationship is now becoming fragile. It can be assumed that the period when human beings could at least believe ⁷ that what constituted a medical service was defined primarily by medical considerations alone is therefore over, even in Western Europe, and that people will thus become increasingly aware that they cannot trust medical institutions unconditionally. The doctor’s role as a mediator in managing one’s own (his or her patient’s) not knowing, therefore, appears problematic yet still indispensable.

Regarding the peculiar features of the problem of “trust,” all these give reason to suppose that in the future, professionals will become more important than ever as actors in the above-mentioned scenarios. The only way we can cope with our old uncertainties about our bodies and worries about systemic aspects of future medical treatment is by relying on the competence of individuals whom we consider equipped with the necessary abilities and moral integrity. In this context, the issue of transference and countertransference particularly assumes a new, greater significance, since how else can we assess whether and how we can trust another person other than in a concrete interactive relationship?

Although the medical profession has undergone a marked loss of power and influence in terms of managing and organizing medical treatment and dealing with health policy issues, their position in the medical decision-making process is stabilizing. As professionals, doctors remain the decisive nodal points since their ability to switch between the different institutional logics and constantly redefine the subject-object relationship remains indispensable.

However, it is important to keep in mind that this situation requires people who are prepared to endure the heavy demands that it imposes. Empowerment as a professional subject depends on the effects on the lived body that arise from all these situations of tension, which the professional must then—facing the emotional demands—manage autonomously. ⁸ How great and complex can the tensions then become for a person assigned a professional’s role yet still allow himself or herself to be affected in a productive way?

Finally, some questions emerge regarding the recruitment of such professionals. Are the potential elites who aspire to a profession in which they can make decisions autonomously still willing, under the current conditions, to venture into the fields of professional action? Are there thresholds at which the empowerment ceases to be productive and degenerates into cynicism or resignation?

In other words, what would happen if, in the future, a decreasing number of people would be willing to rise to the challenge of allowing their lived bodies to be affected by these complex demands? This would result, above all, in the risk of the loss of trust in the system. Consequently, modern society would no longer appear modern since the rationality of its functional relationships could no longer be rendered plausible if no actors were prepared both to recognize and to negotiate the different “modes of existence” (Latour, 2013) with each other dialogically in such a way that autonomy and subjectivity would be promoted in both the doctor and the patient. The arrangement of medical treatment would then be radically changed.

What I have shown here for the medical profession also applies to other professions, which are equally called on to reflect on what autonomy means and how it can be lived and reproduced under the given circumstances. There are of course specific structural differences (e.g., the special characteristics of the conditioning of professionals in law, education and the sciences) arising from the respective influences of society and organizations, as well as dynamics typical of different countries. We can, therefore, expect various arrangements associated with these differences. Thus, each case requires detailed analyses, which can in turn benefit from the analytical, contextural approach. Again, in each case, complex logical spaces need to be related to one another in an arrangement, in turn leading to the development (emergence) of specific configurations of autonomy and subjectivity.